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					             Joint Theater Trauma System Clinical Practice Guideline

                             BLUNT ABDOMINAL TRAUMA
 Original Release/Approval   18 Dec 2004   Note: This CPG requires an annual review.
 Reviewed:     Jun 2010      Approved:     30 Jun 2010
 Supersedes:    Blunt Abdominal Trauma, 7 Nov 08
      Minor Changes (or)      Changes are substantial and require a thorough reading of this CPG   (or)
     Significant Changes

1. Goal. To provide guidance on the management of combat casualties who sustain blunt
abdominal trauma (BAT).
2.   Background.
     a. Unlike penetrating abdominal injuries where the decision to operate is relatively straight
        forward, those combat casualties that sustain blunt abdominal trauma offer more of a
        diagnostic and clinical challenge. With the improvements in body armor, truncal injury
        has decreased despite increasingly more lethal weapon systems. With the advent of
        Improvised Explosive Devices (IEDs), however, more casualties are presenting with
        evidence of BAT. While CT scans are available to assist the provider in decision making
        at a Level III facility, providers at far forward surgical units must decide to operate based
        on physical and Focused Abdominal Sonography in Trauma (FAST) exams.
     b. It is incumbent on the senior surgeon at each facility to ensure the staff understands their
        resource limitations and the inherent limitations associated with the use of the FAST
        exam to diagnose a hemoperitoneum. For those patients with a positive FAST,
        exploratory laparotomy should be undertaken immediately. Rarely, patients with a
        positive FAST and/or CT scan may be managed non-operatively if they are already at a
        Level III facility that can ensure adequate clinical follow-up and evaluation. DO NOT
        aeromedically evacuate patients out of the CENTCOM AOR who have a positive FAST
        exam and/or CT evidence of hemoperitoneum prior to completely assessing and
        controlling any and all ongoing intraabdominal hemorrhage. The benefits of non-
        operative management do not outweigh the risks of an in-flight hemorrhagic emergency
        with no potential for therapeutic surgical intervention.
     c. All grade III-V splenic injuries should undergo splenectomy due to the high failure
        rate of non-operative management with or without splenic embolization. Lacerated
        spleens of any grade with active hemorrhage encountered during laparotomy for any
        reason are best managed by splenectomy. In Level III facilities with Interventional
        Radiology capabilities, consideration may be given to embolization of grade 1/2 splenic
        injuries if the patient has NO other indication for exploratory laparotomy. These patients
        should be hemodynamically stable but with evidence of active bleeding or
        pseudoaneurysm and no evidence of hemoperitoneum on computed tomography. Ideally,
        these patients should be monitored in the MTF for up to 3 days prior to evacuation to
        another MTF. Additionally, the patient’s history should be discussed between the
        referring and accepting surgeons prior to evacuation. This is based on a literature review
        showing 99-100% success rate of non-operative management for grade 1/2 splenic


               Guideline Only/Not a Substitute for Clinical Judgment
                                              June 2010
Page 1 of 3                                                                   Blunt Abdominal Trauma
           Joint Theater Trauma System Clinical Practice Guideline

        injuries. Angiography and embolization for blunt injuries of other visceral organs may be
        used as an adjunctive procedure and should be determined on a case by case basis.
     d. Nothing in this CPG or Appendix precludes the use of exploratory laparotomy for BAT
        when either the clinical or tactical situation warrants.
3. Recommendations. See appendix A
4. Responsibilities. It is the trauma team leader’s responsibility to ensure familiarity and
appropriate compliance with this CPG.
5. References.
1
    Emergency War Surgery Handbook
2
  Nonoperative management of Blunt Splenic Injury: A 5-year experience. Haan JM et al. J
Trauma. 2005;58:492-498.
3
  Correlation of Multidetector CT Findings with Splenic Arteriography and Surgery:
Prospective Study in 392 patients. Marmery H et al. J Am Coll Surg. 2008;206:685-693.
4
  CT Findings after Embolization for Blunt Splenic Trauma. Killeen KL et al. J Vasc Interv
Radiol. 2001;12:209-214.
5
 Observation for Nonoperative Management of the Spleen: How Long is Long Enough?
McCray VW et al. J Trauma 2008;65:1354-1358.
6
  Proximal Splenic Angioembolization Does Not Improve Outcomes in Treating Blunt Splenic
Injuries Compared with Splenectomy: A Cohort Analysis. Duchesne JC et al. J Trauma
2008;65:1346-1353.
7
   Angiographic Embolization for Liver Injuries: Low Mortality, High Morbidity. Mohr AM et
al. J Trauma 2003;55:1077-1082.
8
  Abdomen--Interventions for Solid Organ Injury. Holden A. Int J Care Injured 2008;39:1275-
1289.




     Approved by CENTCOM JTTS Director and Deputy
               Director and CENTCOM SG
          Opinions, interpretations, conclusions, and recommendations are those of the authors
                        and are not necessarily endorsed by the Services or DoD




              Guideline Only/Not a Substitute for Clinical Judgment
                                             June 2010
Page 2 of 3                                                                Blunt Abdominal Trauma
                     Joint Theater Trauma System Clinical Practice Guideline

                                                       APPENDIX A

                                        Blunt Abdominal Trauma (known or suspected)


                                                •   ABC’s and resuscitation
                                                •   Plain radiographs



                                             Head injury requiring immediate
                   Yes                          neurosurgical evaluation?                                 No



         (1) Review CT of Abdomen
                                                                 Unstable Despite Initial                          Stable
                     Or                                              Resuscitation                             Suspect Injury
              (2) DPL or FAST

                                                                     Activate Massive
                                                                   Transfusion Protocol                    CT, FAST or DPL
     Negative               Positive


                                                     Exploratory Laparotomy                 Grade III-V              Grade I or II
     Evac for
   Neurosurgical          Exploratory
    Evaluation            Laparotomy                                                               Indications for OR
                                                                                            (Use Liberal Indications for OR)

                                                                    Yes
                                                                                                               No

Guidelines apply for Level II+ and Level III with                                              CT Evidence of a Contrast
surgical capability                                                                            Blush or Pseudoaneurysm
Fast exam reliability is very operator dependent.
Providers who rely on FAST exam are to be mindful
of risk of false negative exam. Only providers with                                          Yes                       No
personal experience of accurate findings should rely
on the FAST exam as a screening tool for                            Consider Angiographic                            Observe
hemoperitoneum.                                                         Emoblization
If angiographic embolization is to be attempted, the
patient should remain in the facility for a 3 day
                                                                                                                      Stable
observation period before being transported to                            Successful
another facility.

                                                                                                                No          Yes
                                                                     No            Yes



                                                               Exploratory Laparotomy                 Non-operative Management

                         Guideline Only/Not a Substitute for Clinical Judgment
                                                         June 2010
          Page 3 of 3                                                                    Blunt Abdominal Trauma

				
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